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SAAD DIGEST

JOURNAL OF THESOCIETY FOR THE ADVANCEMENTOF ANAESTHESIA IN DENTISTRY

VOLUME 22 | MAY 2006

2005 ConferenceOutcomes of PatientsReferred tothe Sedation Suite

Mentors for Sedation

CONTENTS

SAAD DIGEST | VOL.22 | MAY 2006 1

SAAD Trustees:

- D. Craig, BA, BDS, MMedSci, MFGDP(UK), MBCS, CITP,President

- C. Holden, BDS LDSRCS(Eng) DGDP(UK),Immediate Past President

- D. Terry, MB BS FRCA, President-Elect- D. Debuse, BDS MFGDP(UK), Hon Secretary- S. Jones, BDS, MSc, DDPHRCS, Hon. Treasurer- B. Devonald, BDS LDSRCS MFGDP, Membership Secretary- C. Mercer, PhD BDS FDSRCS ILTM, DSTG, Representative- W. Hamlin, MB ChB Leeds DRCOG, FRCA, ADA,

Representative- P. Averley, BDS DGDP(UK) RCS Dip SED MPhil PhD- C. Boyle, BDS MFGDP FDSRCS MMedSci MSNDRSEd- A. Macpherson, BDS(Edin), MFDS RCSEd, MSND RCSEd,

Dip Con Sed(N’castle)- N. Robb, TD, PhD, BDS, FDSRCSEd, FDSRCPS,

FDS(Rest Dent), ILTM- M. Wood, B.ChD(Stel) MSc(Sed&SpCD) MF GDP MRD

RCS(I) M SND RCS (Ed)

The SAAD Digest is published each January and the SAADNewsletter each June annually by the Society for theAdvancement of Anaesthesia in Dentistry.

Editorial Board:

P. AverleyW. HamlinA. MacphersonC. MercerN. RobbF. Wraith

Original articles and correspondence should be addressed to:F. WraithExecutive Secretary21 Portland Place, London, W1B 1PYTel: 020 7261 8893E-mail: SAAD [email protected]

The subscription rate is £25 (UK) and £28 (international) perannum and includes the SAAD Digest and SAAD Newsletterwhich are published on behalf of SAAD, 21 Portland Place,London W1B 1PY.

ISSN 0049-1160

The cover photograph is a scanning electro-micrograph of midazolam(versed). It is reproduced with the kind permission of the NationalHigh Magnetic Field Laboratory, Florida State University.

2 Editorial

3 Outcomes of Patients Referred to the

Sedation Suite

by A. D. Wallace

11 Profiles

18 2005 Conference

21 Mentors for Sedation

23 Forum

24 DSTG Report

27 Journal Scan

30 Product News

31 SAAD Supplies

32 SAAD Subscriptions

34 Guidelines for Authors

40 Diary Scan

EDITORIAL

2 SAAD DIGEST | VOL.22 | MAY 2006

Welcome to the first editionof the newly revised SAAD

Digest. After Andrea Wraithresigned as Editor of the Digest,SAAD Council decided to carry outa review of our publication strategyand appointed a sub-committee toreview our policy for publications.This has resulted in the loss of ayear of publications of the Digest,but we hope that this new issuewill be worth waiting for!

I would like to thank Bill Hamlin,Avril Macpherson and ChrisMercer for their input to thedeliberations. I would also like torecord my special thanks to FionaWraith, our Executive Secretary,for her help in the organisation ofour ‘new Digest’. The team willform the Editorial Board, alongwith Paul Averley and me. Ouraim is to publish an annual editionof the Digest, which will report onour Annual Symposium as well ascontaining other peer-reviewedscientific papers.

The SAAD Digest has been heldin high regard for many years bythose practising sedation. It hascontained many seminal papers thatare often quoted as the basis fordifferent aspects of practice.However, the articles have neverpreviously been subject to peerreview. Adopting this process willenhance the reputation of thepublication.

The theme of the AnnualSymposium last year was ‘TheEuropean Perspective’. We hadinvited speakers from Italy,Germany, the Netherlands, France,Israel and Portugal to give us anupdate on the provision of sedation

in their countries. The abstracts oftheir presentations are publishedhere along with a report of the day.I hope this will encourage some ofyou who have never attended oneof our symposia to think again thenext time the flyer drops throughthe letterbox!

We will include other areas in theDigest so that it will not lose thefriendly advice approach that hasbeen so valued by members overthe years. I am particularly pleasedthat in this issue we have a paperon the subject of mentoring,written by Derek Debuse. Thissubject is one that is fundamentalto the teaching of sedation, as itprovides a way of bridging the gapbetween the training provided bythe SAAD sedation course andindependent practice.

We also felt that the launch of thenew Digest would be a good timefor the Council members tointroduce themselves to themembership. Thus we have askedall the Council members to write ashort piece about themselves forinclusion in this Digest.

Peter Milgrom has been appointedto the GKT Dental School as a

visiting professor funded by SAAD.This is the first such appointmentin the UK. The appointment isviewed as an excellent use of ourcharitable funds and an opportunityto move pain and anxiety control indentistry forward on a firmscientific basis. In future issues ofthe Digest we aim to have articlesfrom Professor Milgrom, who isbased in Seattle, USA. As he hasyet to have his first visit to hisChair at GKT, we have asked himto introduce himself to themembership in this issue as aforerunner to future articles.

The successful Journal Scan willbe continued as a roundup ofinteresting and relevant articles thatwe feel are of value to themembership.

The format of the Digest is not setin tablets of stone! We are morethan happy to consider suggestionsof how it may be made morevaluable to the membership, aswell as any articles for publication.You will hopefully find the Forum,‘agony aunt’ section both entertainingand informative! Any questionsgratefully received. As the sayinggoes, if you like what you see,please tell others; if you don’t likewhat you see, please let us know.

The 21st century will hopefullycontinue to be an interesting timefor those of us practising conscioussedation in dentistry. Our aim is toinform and update on issues ofinterest to the SAAD membership,and to the wider community ofthose providing high-quality painand anxiety control in dentistry.

Happy reading!

SEDATION SUITE


BackgroundFollowing the publication of A Conscious Decision1 in

2000, the use of general anaesthesia in the provision ofdental care was limited to a hospital setting. This change ledto a dramatic decrease in the number of general anaestheticsadministered and shifted emphasis onto the use of conscioussedation in both primary care and hospital settings2.

The effective management of dental pain and anxiety is ofparamount importance for patients requiring dental care.According to the 1998 Adult Dental Health Survey2, 68%of people moderately or strongly agreed with the statement‘I am nervous of some kinds of dental care’. In many cases,this anxiety can be managed via the establishment of agood dentist–patient relationship, behavioural techniquesand the use of effective local analgesia. However, patientswith higher levels of dental anxiety or phobia tend toactively avoid attending the dentist, fail to attendappointments or simply feel unable to cope with any formof treatment. In these situations, the use of conscioussedation can form an invaluable means to deliver vitaldental care, as pain and anxiety control is an integral part ofdentistry3.

The role of conscious sedation is not limited solely to themanagement of dental anxiety. Other dental indications forits use are moderately difficult or prolonged proceduressuch as extractions, removal of wisdom teeth, implants, or inorder to alleviate anxiety-induced gagging. Within a

medical context, it may be used to reduce the psychologicalresponse to stress and so reduce the activity of thesympathetic nervous system, aiding in the management ofhypertensive patients or those with angina. Furthermore,the muscle-relaxant properties of the benzodiazepines areuseful in the control of spasticity disorders such as multiplesclerosis, Parkinsonism and cerebral palsy, while theiranticonvulsant activity may benefit epileptic patients.

There are two standard techniques currently used:1) Inhalational sedation using a titrated mixture

of nitrous oxide and oxygen2) Intravenous sedation using a single drug,

usually midazolam.

Other, more ‘advanced’, methods of sedation involve theadministration of midazolam either orally or viatransmucosal techniques. However, only experiencedsedationists should employ these methods.

No single technique will be effective in all patients or in allclinical situations. The technique that is chosen must betailored to provide the most appropriate anxiety relief forthe individual patient. As a general rule, the simplesttechnique should be used in all cases4. In certain situations,for example in the treatment of a needle-phobic patient, itmay be necessary to utilise adjunctive therapy using bothinhalational and intravenous sedation, the former techniqueinitially providing sufficient anxiety relief to allowcannulation.

OUTCOMESOF PATIENTSREFERRED TO THESEDATION SUITE,SCHOOL OF DENTISTRYWALES COLLEGE OF MEDICINECARDIFF UNIVERSITY

A. D. WallaceFinal Year Undergraduate,School of Dentistry, Cardiff University

SEDATION SUITE

4 SAAD DIGEST | VOL.22 |MAY 2006

Conscious sedation can be defined as ‘a technique in whichthe use of a drug or drugs produces a depression of thecentral nervous system enabling treatment to be carried out,but during which verbal contact with the patient ismaintained throughout the period of sedation’4. Thedefinition places emphasis upon the safety issuessurrounding the provision of conscious sedation. There areseveral reports relating to sedation risks, safety, standardsand techniques5, 6. Although the current recommendations3

state that the long-term treatment aim for the dental-phobic patient ‘should be a graduated introduction totreatment under local anaesthesia’ using conscious sedationonly as an intermediary stage in achieving this target3, fewstudies have investigated the role of sedation inacclimatising patients to receiving conventional treatmentusing local analgesia.

ObjectivesThe Sedation Suite at the School of Dentistry in Cardiffhas received an increasing number of referrals requestingconscious sedation as a mode of pain and anxiety controlsince its opening in 2000. The study presented here aimedto investigate the quality and details of referrals to theSedation Suite, the treatments provided, the success ratesassociated with each sedation technique, and theeffectiveness of sedation in acclimatising patients toreceiving conventional treatment under local anaesthesia.

Method125 questionnaires (Appendix) were completed using thefiles of patients seen at the Sedation Suite between 2000and 2004. For each year, 25 files were randomly selectedand examined.

ResultsPATIENT GENDER AND AGE

• 76% of patients were female• Mean age was 34 years (range 16–75 years)

WAITING TIMES• Mean waiting time for the first appointment at the

clinic was 15 months after the date of referral tothe Dental Hospital

REFERRALS1. Source

• GDP 60.8%• HDS 35.2%• CDS 0.8%• Other 2.4% (missing data as no referral letter in

file 0.8%)

2. Content of referral letters• 51.2% included the treatment required• 33.6% included a medical history• 24% suggested the use of a particular sedation type• Only 6.5% of referrals included all three of the above

components. Of these referrals:• 75% were received from the HDS, with 37.5% from

the Examination and Emergency Department, 25%from the Periodontology Clinic and 12.5% from theAdult Dental Health Department

• 25% were from GDPs

• A specific treatment modality was requested in thesereferrals:• 37% suggested IV• 20% suggested GA• 17% suggested RA• 17% suggested either GA or a sedation• 3% suggested oral sedation• 3% suggested hypnosis• 3% suggested either RA or IV sedation

SEDATION SUITE


• When specified, over 30% of patients were referredrequiring several different types of treatment, forexample, conservation, extractions and periodontaltreatment:• 74% required restorative dentistry (simple or

complex)• 32% required extractions (simple or surgical)• 14% required periodontal therapy• 6% required prosthetic care

OUTCOME OF FIRST APPOINTMENT52% of patients were assessed at their first appointment.Of these, 2% were deemed unsuitable for sedationtreatment (usually on medical grounds), and 1% of patientswere referred to another department (in all cases, this wasto the Oral Surgery Department for a general anaestheticor surgical treatment under sedation).

The Sedation Suite had a DNA rate of 13.6% and acancellation rate of 1.6%. The DNA rate comparedfavourably with the Cardiff Dental Hospital DNA rate,which currently stands at 14.1%. This result was surprising,since it had been anticipated that the suite would have amuch higher DNA rate as anxious patients often use suchavoidance techniques6.

A full assessment could not be carried out for a smallnumber (0.8%) of patients without use of sedation as theywere too nervous to allow a full examination. In thissituation, a treatment plan was formulated after a thoroughclinical examination under an appropriate sedationtechnique. 27% of patients had previously receivedsedation treatment at a different clinic at the hospital, andwere treated at their first appointment at the SedationSuite.

OPERATOR• Undergraduate 42.8%• GDP/Lecturer 25.5%• Associate Specialist 25.5%• Postgraduate 4.2%

At Cardiff, undergraduates are assigned the simplermanagement or treatment cases, as the rationale during theearly stages of learning sedation techniques is that thedentistry should be simple to allow the student toconcentrate on patient management. The academic staff orTrust staff combine to treat the more complex cases,whether this is in terms of the treatment(s) required or thelevel of anxiety or disability experienced by the patient.Initially, some patients were treated by staff members butthen deemed suitable for treatment by postgraduates orundergraduates. Where this occurred, the mostinexperienced operator was recorded as the representative.

TREATMENT TYPESIn many cases, the referrer requested that the SedationSuite undertook all treatments necessary. The percentagesof each of the treatment modalities provided were:

• Simple conservation 82.4%• Complex conservation (root canal therapy, crown

preparation and bridge work) 54.6%• Scale and polish only 45.4%• Extractions 34.5%• Prosthetics 6.7%• Oral surgery (surgical extractions) 3.4%• Periodontal therapy 2.5%

Where prosthetics treatment was carried out, this wasinvariably due to the patient suffering a pronounced gagreflex requiring control via inhalational sedation.

SEDATION SUITE


NUMBER OF APPOINTMENTS AT THE CLINICOn average, each patient was seen at the clinic six timesbefore treatment was completed.

SEDATION TYPES AND SUCCESS RATESThe types of sedation used and their relative success/failurerates are detailed below. In some cases, a particular type ofsedation was associated with success at some appointmentsbut with failure at others. It would be inaccurate to includesuch occurrences as failures and they have therefore beencategorised as ‘both’ in the graphical representation.

1. RA sedation• Used with 47.9% of patients• 84% success rate• 7% both successes and failures

2. Oral sedation• Used with 4.2% of patients• 80% success rate

3. IV sedation• Used with 59% of patients• 94% success rate• 3% both successes and failures

4. Adjunctive treatment using IV and RAsedation• Required in 4% of patients• Reasons for use:

• RA sedation alone did not provide sufficientanxiety relief

• RA sedation used initially to gain vasodilatation tomake cannulation easier

• Once titration of midazolam was undertaken, the RAsedation was removed so that the definition ofconscious sedation was maintained

5. General anaesthesia referral• 1% of patients

It can be seen that these figures do not equal 100%. Thereasons for this are that as their treatment plan progressed,

some patients felt capable of undergoing treatment using adifferent, and often less potent, method of sedation. Thisconcept will be explored later in the discussion.

TREATMENT PLAN COMPLETIONPrior to commencement of sedation procedures, a treatmentplan must be formulated and explained to the patient.Informed consent should then be gained in writing beforeany treatment is implemented.

• In 46% of the cases analysed, all stages of thetreatment plan were completed and the patient wasrestored to ‘dental health’.

• In 27% of cases, not all stages of the treatment planwere completed. This was mainly due to the fact thatthe patients failed to attend their appointments.

• The remaining 27% of patients were still receivingtreatment and the treatment plan was categorised asbeing ‘ongoing’.

POST-TREATMENT OUTCOMEAs mentioned above, a primary aim of the study presentedhere was to investigate the effectiveness of sedation inachieving acclimatisation. The following points detail thefuture treatment requirements of patients who hadreceived treatment in the Sedation Suite.Following completion of their treatment plans:

• 28% remained as IV sedation patients• 16% remained as recall patients

who would require inhalational sedation forany treatment

SEDATION SUITE


• 11% were successfully acclimatised to receiving all oftheir treatment under local anaesthetic only

• 3% felt capable of receiving some treatments withoutany sedation

• 1% remained as oral sedation patients• 9% were referred elsewhere (usually back

to their GDP or to the prosthetics department)• 31% were placed in the ‘other’ category

(usually because they failed to attend any recallappointments)

DiscussionREFERRAL LETTERSA full discussion of referral letters is beyond the scope ofthis paper. It appears that certain areas of the dentalservice, usually internal referrals made by thePeriodontology and Exam & Emergency Departments ofthe Dental Hospital, provided a higher-quality referral.However, our results have not been analysed sufficiently tomake any firm assertions regarding this. The brief overviewand analysis that we have provided, however, wouldsuggest that the overall quality of the referral letters wasvery poor. Referrals such as ‘please see and treat thispatient who is needle-phobic’ are inadequate andinappropriate but were not an uncommon finding duringour study.

The ideal referral letter should contain:• The reasons and justification for the use of conscious

sedation• Any relevant medical history• The treatment required• Any relevant dental history• An indication as to whether the referral is for a single

procedure or whether the patient is being referred forall further treatment

This is a medico-legal document and, as such, the referrershould keep a copy for his or her notes7.

OPERATORAt Cardiff, in the outgoing curriculum, students weretimetabled on a month-long ‘sedation block’ during whichtime they were trained in aspects of sedation and toundertake sedation procedures for four afternoons eachweek. The aim was to gain experience of conscious sedationtechniques with simple dental tasks, such as scaling,conservation, simple endodontics or extractions. It waswidely acknowledged amongst the students that this was a

valuable and inspiring experience. In the final year of study,ten students were also able to undertake a specialisedstudy of conscious sedation, enabling them to gain furtherknowledge and experience in this area.

The teaching of conscious sedation is a recent addition tothe undergraduate curriculum. Currently, few dentists havehad conscious sedation experience as part of theirundergraduate course, or have undertaken anypostgraduate training. This lack of experience may, in part,contribute to the large numbers, and poor quality of referralletters8.

SEDATION TYPES, TREATMENT TYPESAND SUCCESS RATESThe modes of treatment provided by the clinic werepredictable, with simple and complex conservative dentistry(RCT, crown and bridge work), scaling, subgingivaldebridement and extractions forming the predominanttreatment types. It is unsurprising that many patientsrequire restorative dentistry, extractions and some simpleperiodontal therapy, because of either having neglectedtheir oral health or poor dental attendance for many years.Neglect, combined with the greater levels of invasivenessand trauma associated with more complex restorativeprocedures and extractions, probably accounts for the highlevels of necessity of these treatments.

The high success rates associated with all modes ofsedation underline its effectiveness. It is an invaluablemeans of treating nervous or medically compromisedpatients, and the referral of only 1 out of 125 patients inthis sample for general anaesthesia serves to emphasise itsimportance in reducing the demand for this service and itsassociated risks.

48% of patients were treated at some point underinhalational sedation, with 59% of patients receiving IVsedation. This split highlights the fact that no singletechnique will be effective for all patients or indeed for alltreatments. In line with the SDAC/DoH guidelines of2003, the technique requiring the least intervention tomatch the patient’s requirements should be used9.

ACCLIMATISATIONThe results of this study suggest that sedation is effectivein achieving acclimatisation in some patients, and that theDental Hospital is following the recommendations thatsedation is used only as an ‘intermediary’ measure whereverpossible3.

SEDATION SUITE


The absolute effectiveness of sedation in allowingacclimatisation is difficult to interpret given the broad rangeof treatments provided by the sedation clinic. Sometreatments, such as extractions or surgical procedures, willbe associated with higher anxiety levels than less invasiveprocedures, such as a scale and polish. It would therefore benecessary, in a further study, to look at only one treatmentmodality in order to assess the rate of acclimatisationachieved via treatment with sedation. The complexity of thepsychological components associated with dentistry,however, may confound such a study, as patient anxiety andtolerance levels are associated with factors such as stress,mood, health and life events. Furthermore, according toFreeman’s psychodynamic theory of dental phobia, anxietyis related to false connections and displacement9. That is, apatient makes a false connection between dentistry andanother adverse life event and transfers their fear over.Thus, a procedure that invokes fear in one patient may notin another.

ConclusionOverall, the standard of referral letters is consistently poorand it is the recommendation of this report that pro formasconforming to the ‘gold standard’ 7 are made universallyavailable. Currently these are only available to members ofthe Dental Sedation Teachers Group (DSTG) and SAAD.

Undergraduates at Cardiff are provided with reasonablelevels of experience in the provision of conscious sedation,in line with the recommendations published by the DSTGregarding training requirements in the document TheCompetent Graduate10. However, they have not seenenough clinical cases to have reached full competency andwould require further postgraduate training and supervisedclinical practice to achieve the competencies asrecommended by the DSTG10, 11.

All modes of sedation are associated with high levels ofsuccess, underlining its value and the skills of the clinicianin selecting the appropriate mode of sedation based onpatient factors and the treatment type. The waiting list timeof fifteen months for an assessment appointment at theclinic at Cardiff is considerable and problematic given thelevel of dental need in patients referred for this service.Given the value of sedation highlighted by this study, itwould appear that expansion and future investment in theprovision of conscious sedation is warranted.

Bibliography1. A Conscious Decision. Report of a Group chaired by

the Chief Medical and Chief Dental Officer.Department of Health; July 2002.

2. Adult Dental Health Survey. www.statistics.gov.uk3. Maintaining Standards. General Dental Council;

November 2001.4. Conscious sedation in the provision of dental care.

Report of an expert group on sedation for dentistry.Standing Dental Advisory Committee/Department ofHealth; 2003.

5. Implementing and ensuring Safe Sedation Practice forhealthcare procedures in adults.UK Academy of Medical Royal Colleges;November 2001.

6. Standards in conscious sedation for dentistry.Report of an independent expert working groupconvened by the Society for the Advancement ofAnaesthesia in Dentistry; October 2000.

7. Conscious Sedation: A Referral Guide for DentalPractitioners. Dental Sedation Teachers Group;September 2001.

8. Leitch J A, Girdler N M. A survey of the teaching ofconscious sedation in dental schools of the UnitedKingdom and Ireland. BDJ. Feb 2000;188(4): 211–216.

9. Freeman R. A psychodynamic theory for dentalphobia. BDJ. Feb 1998; 184(4): 170–172.

10. Sedation in dentistry: The Competent Graduate.Dental Sedation Teachers Group; 2000.

11. Training for Safe Practice in Advanced SedationTechniques for Adult Patients.Dental Sedation Teachers Group; 2004.

12. McGovern A. Review of conscious sedation teachingto undergraduates in both Cardiff and Dublin DentalSchools. UWCM Elective Project.

13. Dark N, Parkhouse E. A comparison of the levels ofpatient anxiety and knowledge of different treatmentmodalities in different clinical settings in Cardiff.SAAD Digest. Spring 2003; 20(1).

AcknowledgementsDr S. Thompson BDS, MPhil, PhD, MSND RCSEdMr J. Collis, final-year undergraduate at the School ofDentistry, Cardiff University.

Appendix


1) MALE FEMALE AGE

2) DATE OF REFERRAL ........ / /

3) SOURCE OF REFERRAL

GDP

CDS

Hospital Dept .... specify ___________

Other ................. specify ___________

4) ORIGINAL REFERRAL – QUALITY/CONTENT

Medical history

Sedation type .... specify ___________

Treatment type .. specify ___________

Not stated

5) PATIENT STATUS

New patient at Sedation Suite

Existing sedation patient at Dental Hospital

6) DATE OF FIRST APPOINTMENTAT SEDATION SUITE ........ / /

7) OUTCOME OF FIRST APPOINTMENTAT SEDATION SUITE

Assessed (go to question 8)

Treated (go to question 10)

DNA

Cancelled

Other .............. specify_____________

8) ASSESSMENT APPOINTMENT OUTCOME

RA sedation W/L

Oral sedation W/L

IV sedation W/L

Unsuitable medical grounds Referred to GA

Further referral CDS UDH/GDP O/S

9) SEDATION CATEGORY ALLOCATION

Simple (U/G)

Medium (junior staff/postgrads)

Difficult (senior staff)

OUTCOME OF REFERRALSTO THE SEDATION SUITE IN ADH [UWCM]

Appendix


10) OPERATOR

U/G (sedation block)

U/G (final year/specialised options)

Postgraduate (trainee)

GDP in ADH

Lecturer

Associate Specialist/senior staff

11) TREATMENT REQUIRED/ADMINISTERED

S+P

Simple cons

Extractions

Prosthetics

Complex cons

Oral surgery

Periodontal treatment ONLY

12) OCCASIONS TREATED UNDER SEDATION

Number

13) OUTCOME OF SEDATION APPOINTMENTS

RA sedation success failed

Oral sedation success failed

IV sedation success failed

RA + IV sedation needed

Oral + IV sedation needed

GA needed

Other .............. specify_____________

14) TP COMPLETED

Yes

Ongoing

No .................. specify_____________

15) POST-TREATMENT OUTCOME

Acclimatisation – conventional treatment (LA)

RA sedation patient

Oral sedation patient

IV sedation patient

GA patient

Referred elsewhere .. specify________

Other ....................... specify________

PROFILES


My wife Linda’s (going on 36 years)favourite story about me was

when the Dean of the dental schoolwhere I studied (University ofCalifornia, San Francisco, class of 1972)gave me a big bear hug at thegraduation ceremony when everyone

else received the formal handshake.I had been a rather difficult studentleader and she says he was very glad tosee me go. As students we were not veryhappy with the curriculum we weretaught so we organised a kind ofalternative school at night and Saturdaysbringing in speakers from other schoolsand the community. That was how, forexample, we learned about hypnosis.Actually he was secretly happy aboutwhat we did but never properly said so.According to my Dean now at theUniversity of Washington in Seattle, Iam not much better.

We started the Dental Fears ResearchClinic in Seattle back in the early 1980s.We initially focused exclusively onpsychological strategies and thenexpanded to encompasspharmacological approaches. WhenI wanted to learn sedation techniques

PETERMILGROM

I am married with three children. I enjoy sailing, skiing, squash and

motor sports.

I qualified in 1990 from the Universityof Newcastle upon Tyne, and in 1997completed the Diploma in GeneralDental Practice at the Royal College of

Surgeons of England and the Diplomain Conscious Sedation at theUniversity of Newcastle upon Tyne. In2002 I completed a sedation-basedMPhil and in 2005 a sedation-basedPhD. I am currently engaged with aDental Implantology MSc.

Since 1994 I have been the principalof Queensway Dental Practice andQueensway Anxiety ManagementClinic, located on Teesside. ThePractice provides primary dental careand specialises in the management ofanxious children and adults. It offers areferral-based anxiety managementand oral surgery service to over 200dental practitioners in the region. Theteam includes ten dentists, fiveconsultant anaesthetists, three dentalsurgeons, four hygienists, one practicemanager, one clinical governance lead,twenty-seven dental nurses, sevenreceptionists and four cleaners.

In 1998 I established the Clinic as afirst-wave Personal Dental Services

pilot with the support of Tees HealthAuthority in order to reducedependence on general anaesthesiaand to increase the use of conscioussedation techniques for referredpatients. Our service caters for thecare of more than 10,000 referredpatients per annum.

I have a special interest in conscioussedation and also primary careresearch, and have been lucky enoughto have been funded through an NHSPersonal Development Award tofurther both of these interests. As aresult of the published output of theseactivities, I am involved in developingsedation policy by being part of anexpert advisory group looking at ‘theprovision of conscious sedationservices’ at the request of the StandingDental Advisory Committee. I alsochair a primary care research networkthat seeks to develop researchcapacity in primary dental care.

I went all over the dental school askingdental colleagues to teach me and noneof the traditional fellows would sharetheir secrets. So I reluctantly went to seethe professor of anaesthesiology in themedical school who promptly set me upwith training in one of the university-affiliated hospitals. Much the samephenomenon happened when I decidedto expand our research programme insedation. The best part is now I havefriends in disciplines from psychiatry topharmacology.

I have two grown up children. My son inSeattle was trained as a lawyer andworks in business. My daughter inWashington DC is an event planneralthough she recently quit a job she didnot like and is working as a barrista atStarbucks. I can speak passable Italian,especially after a couple of grappas, andplay rather amateurish piano.

PAUL AVERLEY

PROFILES


After qualifying at GlasgowUniversity I left for a hospital job

in Manchester. Twenty years later Ihave still to make it back to Scotland.

In Manchester I spent six months asan SHO in Dental Anaesthesia andsubsequently completed an MMedSciin Sheffield in the same subject.Despite forays into oral surgery andgeneral practice, this early job set meup to become a dental sedationist.

I now work full time in theDepartment of Sedation and SpecialCare Dentistry, King’s College LondonDental Institute at Guy’s, King’s

CAROLE BOYLE

Following 12 years as an IBMsystems analyst at University

College London, I decided to becomea dentist – still not quite sure why!However, in 1983 I passed all thequizzes and graduated fromManchester Dental School.

My first appointment was ResidentHouse Officer in Oral Surgery at

Manchester Royal Infirmary. This wasfollowed by 6 months as an SHO inDental Anaesthesia and then 18months as a Lecturer in Oral Surgery.

We next moved back to the Southeast,where I worked in a number of generalpractices and also part time at theKent and Sussex Hospital inTunbridge Wells and at Guy’s. After afew years and a lot of worrying aboutmy prospects of ever finding what myMum used to call a ‘proper job’,I decided to consolidate my knowledgeand practical experience of generalanaesthesia and sedation bycompleting an MMedSci degree in theDepartment of Anaesthesia atSheffield University.

In 1991 I joined Meg Skelly in theSedation Unit at what was then calledUMDS (United Medical and DentalSchools of Guy’s and St Thomas’Hospitals). In 1996 the Sedation Unitjoined with the Special Needs Unit tobecome the Department of Sedationand Special Care Dentistry.Somewhere along the line UMDSchanged its name to GKT (Guy’s,

King’s and St. Thomas’) and then toKCL (King’s College London) DentalInstitute. I took over from Meg asHead of Department in 2002. Thedepartment has undergraduate andpostgraduate teaching commitmentsand also provides treatment for phobicpatients and individuals withdisabilities who cannot be treated ingeneral practice or the CDS.

I have now been teaching on theSAAD National Course for over tenyears and have been Course Directorfor nearly five years, while myPresidency of SAAD finishes later thisyear. I am Chairman-elect of theNational Examining Board for DentalNurses, an organisation for whichI have great respect and with whichI have worked for many years.

In what passes for leisure time, I enjoytravel and (gentle) cycling with myfamily and I am also involved in anumber of activities relating toamateur radio. My call sign (G2HIX)was passed to me by the family ofGerry Holden, a former President ofSAAD.

College and St Thomas’ Hospitals asan Associate Specialist. My particularinterests are using sedation for peoplewho require special care and teachingsedation both to undergraduates andpostgraduates.

I have been a trustee of SAAD forthree years and have enjoyedorganising the annual meetings. I am amember of the SAAD course facultyand am Chairman of the DentalSedation Teachers Group (DSTG).

Outside work my hobby is running:currently, I am training for my thirdLondon Marathon. I am a Level 2athletics coach and organise a group ofwomen runners in the East End ofLondon.

DAVID CRAIG

PROFILES


DEREK DEBUSE

The year after qualifying from the Royal Dental Hospital in 1966,

I attended my first SAAD course atUniversity College. I emergedclutching my armboard, a length ofplastic tubing and a bottle of Brietal.In order to practise my new-foundskills, I joined a practice in sunnyBognor Regis. I had just started to getthe hang of ‘twilight sleep’ whenValium came on the scene andimmediately all my patients wereconverted to benzodiazepines(admittedly with a little Fortral added).

In 1974 I bought my own practice inBillingshurst and, in order to avoidMonday mornings, took on a post backat ‘The Royal’ as Demonstrator in theConservative Department. On themerger (more like a submerger) of theRoyal and Guy’s, I crossed the riverand joined the Cons Department atUMDS, as it was then called. I soongot talking to both Meg Skelly and IanNelson about sedation, as they werevery active within the Sedation Unit,

I qualified from King’s College Hospital in 1970 and did a

maxillofacial house job there, and thenjoined a general practice for a year inChertsey. I became disillusioned withgeneral practice but went on a SAADcourse and met Ian Brett and JohnHarrison, with whom I worked for twoand a half years. This rekindled myenthusiasm and I learned anenormous amount, not only aboutsedation and anaesthesia, but alsoabout the delivery of dental care.

In 1975 I moved to Lincoln, where Icreated a purpose-built dental practicepromoting sedation and anaesthesiafor dentistry. This grew very quickly tofour dentists, who have worked

which even then was teachingsedation techniques to undergraduatestudents. As soon as a vacancycropped up I applied, and joined themfor one day a week in 1989. Four yearslater, I expanded that to two days.

I became the first Secretary of theDental Sedation Teachers Group,then Chairman some years after. I alsoserved on the Sedation sub-committeeof the National Examining Board forDental Nurses for some years. MySAAD membership never lapsed, butin 1998 I got involved in teaching onthe SAAD courses. I was then put in

together since 1982, quite anachievement!

For many years I served on many localcommittees, including the BDA, LDC,FPC, FGDP and regional dentaladvisory committees. I have been amember of SAAD since 1972 and aCouncil member, with specificresponsibility for membership, for tenyears. I have helped to organise theSAAD Annual Conference andpresentations at BDA Conferences.

I am married to a gynaecologist andwe have two ‘grown-up’ children. I amnow approaching the time when I canspend longer indulging in my hobbies,which include skiing, trekking, sailingand driving my Morgan!

BARRYDEVONALD

charge of registrations for the courses,and was made Hon. Secretary ofSAAD last year.

I relax by playing music (a veryamateur pianist) and run the musicclub in my home town. When timeallows, I enjoy a few calming hours atthe lakeside fly-fishing for trout.

I am married (38 years and still goingstrong!) and have two children. Myson is a horticulturalist who works forthe National Trust in Northumberland,and my daughter is a fourth-yearregistrar anaesthetist.

PROFILES


My interest in dental anaesthesia started when I was a Registrar

on the Leeds rotation. I was taken tovarious practices by one of theanaesthetic consultants, taking with usan early pulse oximeter. We were lookingat the saturation profiles of patientsduring dental-chair anaesthesia usinghalothane and 20% oxygen; this becamea presentation for the AAGBIRegistrar’s Prize. As a Senior Registrar Iconducted another study looking atarrhythmias during halothane chairanaesthesia, recording the ECG on a24-hour cardiac monitor. I also starteddoing chair anaesthesia for a friend whohad just started up in practice.

On becoming a Consultant I wasasked by a retiring colleague to takeover her chairside practice. This I did,and continued to anaesthetise in onesurgery until general anaesthesia wasfinally prohibited outside hospitals; inall I gave over 10,000 anaesthetics in

both adults and children. I thenbecame the lead clinician, bringingpaediatric dental anaesthesia intohospital, a list I still do. I also have aweekly dental conservation list forpeople with special needs.

My training in committee work andeducation started with the JuniorAnaesthetists’ Group, now GAT, anational committee representingtrainees on all the national associationand college committees. I have beenClinical Tutor for ten years, thenCollege Tutor for three years, and nowDepartmental Director for three years.

I have been a member of ADA forfifteen years and of SAAD for two, onADA Council for seven years andTreasurer for two, and therepresentative for ADA on SAAD forthree years. I am looking forward tohelping with the ‘New’ SAAD Digestand will seek election to SAAD Councilonce my term on ADA Council iscomplete.

Lastly, hobbies: I enjoy skiing andwalking, but my real passion issailing.

I run a private practice inChesterfield, Derbyshire devoted to

the anxious and frightened patient.Both my parents were dentists andI started my career early, learning aboutergonomics in dentistry and generalanaesthesia during family mealtimes asa teenager. Turning down employmentafter flying scholarships with the RAFand British Airways, I decideddentistry was more interesting.

Since qualifying in 1981 I have workedboth in hospital and general practice.A significant interest in anaesthesiaand sedation for dentistry has led toinvolvement in developing nearly allthe major guidelines published in thisarea in the last 15 years, includingthose for the General Dental Council,Department of Health and the RoyalCollege. I have lectured worldwide onconscious sedation and continue tocontribute to the international debate

as President of IFDAS (InternationalFederation of Dental AnaesthesiologySocieties). I have been on Council ofADA and the DSTG as well asSAAD.

Involvement in medico-legal cases hasseen me giving defence evidenceconcerning conscious sedation inlandmark cases both at a regulatorylevel and in the civil and criminal courtsin the UK, Ireland and New Zealand.Such evidence is often in relation toallegations of sexual assault, inappropriatepatient management and negligentadministration of sedative drugs.

Flying has never left the system: I am akeen pilot, having qualified on glider,fixed-wing and flex-wing aircraft, and Inow fly helicopters and own a helicoptercompany. I am engaged to Philippa, andwe live in South Derbyshire with onedaughter, Yasmin, and a cat!

CHRISTOPHERHOLDEN

BILL HAMLIN

PROFILES


My present post is Clinical Director of Dental Services,

North Cumbria PCTs, which involvesmanaging a Community DentalService, a PDS Options for Changepilot and three Dental AccessCentres. Clinical activity revolvesaround the provision of inhalationaland intravenous sedation to anxiousand phobic patients referred to theservice and carrying out dental careunder general anaesthesia.

The pilgrimage in conscious sedationbegan for me in 1975 in the company– and with the guidance – of SAAD.The foundations for a continuing

interest in this area of dentistry werelaid following a SAAD course ininhalational sedation, and the benefitsof practising this technique in a busydental practice in West Cumbria werea spur to return the following year forthe intravenous sedation course.

Many years later, in 1996, I wasfortunate to be selected to receiveintensive training in the Dental Schoolat the University of Newcastle uponTyne. In order to promote andfacilitate the use of conscious sedationin dentistry, the Postgraduate Instituteorganised an extended course,Conscious Sedation and Pain Control

I graduated from Edinburgh Dental School in 1986 and subsequently

held a series of junior hospital posts inDundee, Newcastle and the WestMidlands, in prosthodontics and oraland maxillofacial surgery.Following vocational training and someyears as an associate in general dentalpractice, I was appointed as aCommunity Dentist with LothianCommunity Dental Service in 1993,completing the Diploma in ConsciousSedation (University of Newcastle) in1997.

I am currently a Senior CommunityDentist for Special Care and Sedationwith Lothian Salaried Primary CareDental Service, in which I am themanager and clinical lead for a team ofdental professionals providing oral

healthcare for adults and children witha range of special needs. I obtained theDiploma of Membership in SpecialNeeds Dentistry of the Royal Collegeof Surgeons of Edinburgh in 2004.I am concurrently Honorary TeachingFellow, Edinburgh Postgraduate DentalInstitute, and Honorary ClinicalTeacher, Glasgow Dental Hospital andSchool. I examine MFDS for RCSEdand am an examiner for the NationalExamining Board for Dental Nurses insedation and special-care dentistry.

My clinical and research interestsinclude the dental management ofmedically compromised patients,sedation and GA in the managementof adolescents and adults with specialneeds and the oral health of childrenwith special needs.

AVRILMACPHERSON

Leading to Trainer Status in theNorthern Region. Nigel Robb – acurrent SAAD Council member – wasinstrumental in setting up and leadingthis project. The following year theUniversity offered the Diploma courseConscious Sedation in Dentistry, sobetween providing practitioners with‘hands-on’ clinical supervision and theusual work commitments it was backto studying (again) for the Diplomathat was duly awarded in 1997. (PaulAverley, also a SAAD Councilmember, was a fellow colleague duringthose two years of study at Newcastle.)

The National Examining Board forDental Nurses is very persuasive, too!In March and September each year avariety of examination centres acrossthe country are visited to examinedental nurses in the Certificate inConscious Sedation Nursing.

Time out of work is spent with wife,four children and two dogs – not toforget the many hours on the cragsand fells of Cumbria.

STEPHENJONES

PROFILES


I am a Council member of SAAD because I represent the DSTG and

am, I suppose, therefore a bit of aninterloper. However, this doesn’t seem tohave prevented me getting roped in asa member of the Editorial Board of therevamped Digest!

I graduated from St Andrews andmoved down to London to do my

house jobs. The first was at Guy’s in theChildren’s/Ortho Department underJack Tulley and Alan Campbell. Theywere both real gentlemen and taughtme a lot. It was a vintage time, with RayReid, Ernie Crossman, Laurie Usiskinand Eileen Jaffee all in the Department,and Tom Pitt-Ford as my student HS.

After an interesting further six monthsin oral surgery at St Mary’s, Paddington,and after a stiff interview with HarryAllred and Ted Renson, I got the ConsRegistrar’s job at The London, followingin Paul Wright’s shoes. This gave memy first sedation experiences,administering IV Valium under theeagle eyes of Dougie Shepperd. After aspell as a Lecturer in the ExperimentalDental Care Project, I became aLecturer in Conservative Dentistry anda full-time teacher. My Fellowshipcame soon after but the PhD (on lasersin dentistry) took a bit longer!

An Honorary Consultant in RestorativeDentistry, I am now Senior Tutor forDental Admissions as well as LeadClinician for Sedation Teaching andConvenor for the Plaque RelatedDiseases Module. When possible I tryto maintain my laser research activityand am UK representative for theInternational Society for Lasers inDentistry (ISLD).

My main interest is music, and inparticular singing. I conduct the TabardSingers, a small London-based a capellachoir, and also manage to do some solosinging, my most notable achievementsbeing a number of performances as theEvangelist in Bach’s St John Passion.I have sung on 15 commercial CDs, onRadio Four and on BBC2 TV. I also likecars and have an old Riley One-Point-Five and a classic SAAB. Finally, a loveof wine seems to call me to France asoften as Mira and I can make it!

Rotherham District General Hospitaland the Dental Hospital at Leedsuntil 1987. I spent two years at Guy’sDental School in a research post,which led to my PhD thesis on theepidemiology of tooth wear.

I moved to Newcastle as a Lecturer inRestorative Dentistry in 1989, where Ideveloped my interest in sedation,having already been using hypnosis inpractice for a number of years. Duringmy time at Newcastle I was involvedin setting up the first Diploma inConscious Sedation, and was afounder member of the DentalSedation Teachers Group and was thefirst Chairman. I also completedHigher Specialist Training inRestorative Dentistry.

In October 1998, I was appointed asSenior Lecturer in RestorativeDentistry (Sedation), where I wasresponsible for co-ordinating the

NIGEL ROBB teaching of sedation in the DentalSchool in Cardiff.

In September 2001 I took up the postof Senior Lecturer in Sedation inRelation to Dentistry in Glasgow. I amnow developing a sedation-teachingprogramme for the third time, and in athird dental school.

I am on the teaching faculty andCouncil of SAAD, President of theAssociation of Dental Anaesthetists,and a past President of the EuropeanFederation for the Advancement ofAnaesthesia in Dentistry.

My interests outside work includemusic, and I was lucky enough to singfor the BBC National Chorus of Waleswhilst in Cardiff. I enjoy cycling, and inMay last year tackled the C2C fromWhitehaven to Sunderland. I have alsorecently succumbed to a long yearningto own a TVR.

After graduating in Dentistry from the University of Edinburgh in

1982, I worked in hospital posts at theDental Hospital in Edinburgh,

CHRISTOPHER MERCER

PROFILES


DIANA TERRY

I was born in London and studied Medicine at King’s College London,

qualifying in 1975. Having chosenanaesthesia as a career, I was onrotations at King’s and The MiddlesexHospitals, and then spent a year inBirmingham, Alabama.On returning to the UK I obtained aconsultant post in Bristol, with sessionalcommitment to special needs dentistry.Having an interest in teaching and

resuscitation, I became one of the firstnational Advanced Life Supportinstructors for the Resuscitation CouncilUK, and then joined the faculty ofSAAD for the highly successfulLifesaver courses. I was then asked bySAAD Council to be Director of theSedation (Main) course.I have also been a Council member forthe Association of Dental Anaesthetists,and have enjoyed developing trainingfor sedation and anaesthesia withdental and medical colleagues.

I enjoy mountains and open spaces,both in the UK and abroad, fromtrekking in Nepal and Uzbekistan tothe familiar hills of the Lake District,and now live on the Cotswold Way. Weenjoy exploring places off the regulartourist trail, such as Madagascar,

Ecuador and Mali, although myhusband is more of a five-star hotelman, whereas I rather like tents in thewild.

As a working mother of three children,and acquiring three more by marriage,I have extensive experience of jugglingthe work/life balance and the demandsof young people trying to make theirway in the world.Living in Bath, I have been inspired tolearn more about architecture, and havean interest in contemporary fine art andceramics. I am part of a book club thatmeets monthly. I have had a go at avariety of activities – climbing, caving,sailing and scuba diving – and firmlybelieve that no woman can have toomany rucksacks or fleeces, or indeed toomany silk scarves.

MICHAELWOOD

amount of ‘bush dentistry’, particularlyin what is now known as Namibia.The dental clinics in townships in andaround Cape Town occupied my timefor the next few years before I arrivedat Heathrow in 1991 with a backpackto do a bit of travelling and a little bitless dentistry.

At an early stage I was exposed to the‘travelling gasman’ and the ‘fairy liquid’if the adult patients were anxious. DrGideon Bosch then introduced me toconscious sedation in 1992 – and itwas surprising how many adults didnot require GA. After working atLeagrave Dental Anaesthetic Clinicas a part-time associate for a few years,I became the Principal in 1996.

In 1999 I started an MSc in Sedationand Special Care Dentistry at Guy’sand did a project on intranasal sedationin children. At the end of 2001, GAwas discontinued at Leagrave, andProfessor James Roelofse spent sometime there showing some of histechniques that he uses to great successin paediatric sedation.

The Clinic has grown and now hasfour full-time and one part-timedentists and a part-time oral surgeon,plus two part-time medically qualifiedsedationists, and about 6,000sedations are performed annually. Ihave an ongoing audit of over 3,000paediatric sedations.

I am active in giving lectures,especially on paediatric sedation, andthe dental management of patientswho require special care. I am also anexpert witness for the GDC inmatters concerning paediatric sedation.I have been treasurer of BedfordshireLDC for the past five years and amon the Bedfordshire Oral HealthAdvisory Group. On Mondays Inegotiate the rail network for my roleas a part-time clinical lecturer at Guy’sin the Sedation Department.

The family has recently expanded tothree lovely children and a verysupportive wife, Greer. They enjoyskiing and travelling, particularly backto their extended families back inCape Town.

I decided that I would like to do dentistry from about 13 years old.

I was influenced by my own dentistdeciding, at that impressionable age,that he did not manage a naughty,anxious boy very well.

I qualified at Stellenbosch Universityin 1986 with an intolerance to wineand then proceeded to do two years ofNational Service where I did a fair

2005 CONFERENCE


IntroductionThe 2005 Conference was held on Saturday, 22 October

at the Royal Society of Medicine. The title was ‘Sedation:A European Perspective’, and the scientific programme wasdevised by Dr Carole Boyle and Dr Barry Devonald.

The intention was to compare the different approaches toconscious sedation in dentistry as practised throughoutEurope, and this was realised: speakers gave full and frankaccounts of the situation in their individual countries. Thespeakers came from France, Germany, Israel, Italy, theNetherlands and Portugal. All had been asked to answer thesame set of questions so that the situation in the differentcountries could be compared. The questions were:

1. What sort of sedation is practised in your country?2. Who provides sedation – dentists and/or doctors?3. What are the limitations on providing sedation?4. Are there any published guidelines or standards?5. What teaching is carried out in sedation, and do

undergraduate dental students gain experience insedation?

6. Any recent developments?

These countries were chosen as having varying histories interms of the provision of sedation. The contacts wereachieved largely as a result of Dr Nigel Robb’s connectionwith the European Federation for the Advancement ofAnaesthesia in Dentistry.

The result was an illuminating day, many delegates sayingthat it was the best meeting they had attended for manyyears. Carole and Barry are to be congratulated on organisinga highly successful event.

At the end of the conference it was evident that UK dentalsedation is in very good shape indeed. There was anappreciable range of different situations in the countries thatwere represented on the day. This does raise an obviousconcern as to what we can expect of graduates from othercountries arriving in the UK to practise dentistry. If we thinkthat providing postgraduate education in sedation to UKgraduates is difficult, due to the different levels of knowledgeand experience gained at graduation, then we have a biggerpotential problem in the future!

The Annual General Meeting was held at the close of theScientific Meeting.

For those of you who attended the Annual Conference, wehope that the publication of the abstracts will act as anaide-mémoire for the day – and for those who were notpresent, we hope that what you read will entice you to comenext year.

Derek DebuseHon. Secretary, SAAD

SAAD ANNUAL CONFERENCE

Current sedation practicein ItalyGastone Zanette MD, AnaesthesiologistGiovanni Manani MD, Professor of AnaesthesiaMedical School, Department of Dentistry,University of Padua, Italy

MATERIALS AND METHODSEmail and telephone survey to collect data on currentsedation practice in Italy.

SEDATION: A EUROPEAN PERSPECTIVEABSTRACTS

RESULTSIn Italy there are 33 dental schools, 18,921 dentists and34,625 doctors working in dentistry. Sedation is taught in 26dental schools (78%), and Padua University has an educationprogramme on sedation for postgraduate dental practitioners.Sedation in Italian dental schools is provided byanaesthesiologists (94%) and by dentists and doctors (6%).Guidelines for sedation in dentistry in Italy are published bythe Italian Association of Dental Anaesthesia (AINOS). Atpresent, Padua Dental School has a sedation protocol of itsown and is conducting an investigation of the bispectralindex (BIS) during sedation.

2005 CONFERENCE


DISCUSSIONSedation teachers in Italy are anaesthesiologists. Conscioussedation, considered a beginner’s technique, is not theirpreferred topic. Also, sedation techniques for paediatricand/or disabled patients are rarely carried out, because thesepatients are treated mostly with general anaesthesia.Anaesthesiologists perform most of the dental sedationscarried out in Italy. Sedation techniques depend on theexperience and judgement of the teachers, the skill of clinicalstaff and the available resources of the institution. Theseteachings are carried out on a theoretical basis, andmeanwhile practice is lacking in the majority of dentalschools; only Padua University has a postgraduate course onsedation for dentists. There are no standards for sedation indentistry produced by public authorities, but AINOS, in theJournal of Dental Anaesthesia, has published guidelinescovering many aspects of sedation in dentistry.

Current sedation practicein FranceMartine Hennequin, University of Auvergne, France

French dental graduates are required to be competent in theuse of psychotropic drugs in the context of dental care.However, the legal framework is vague and the conditions foruse, the routes of administration and the needs of specificpopulations are not precisely described. Licences for the useof common dental sedative drugs, such as nitrous oxide andmidazolam, are restricted to use in a hospital environment.Moreover, the cost of dental sedation is not reimbursed bythe social security system. Dental sedation is thus poorlydeveloped in France.Among the 16 French dental faculties, 4 are involved in anational project that began in 2002 and has so far providedtraining in sedation for 87 postgraduate students. Thisproject aims to verify whether the teaching content of acomprehensive university course is sufficient to achievecompetency for general practitioners. The programmeconsists of 4 seminars of 2½ days over one year, and givestheoretical and practical training in the safe administration ofa 50% nitrous oxide/oxygen premix and of intravenous, oraland intrarectal midazolam. It includes basic teaching inpharmacology, psychology, pain and anaesthesiology.The development of dental sedation in France now dependson a number of different factors:1. Research is needed to demonstrate the efficacy and

tolerance of procedures that could be used in privatepractice.

2. Medical recognition of the needs of specific groups isrequired to improve access to care via sedation.

3. European documents, such as the ADEE initiative, shouldencourage the training of undergraduate students in sedation.

Current sedation practicein IsraelEliezer KaufmanHead of Center for Dental Sedation and Anaesthesia,Department of Oral Medicine,Hadassah School of Dental Medicine, Jerusalem

The first dental ordinance in Israel was created in 1945according to British law under the British Mandate in whatwas then Palestine. In 1991, dentists practising sedationformed the Israeli Society for Sedation, Analgesia andAnesthesia in Dentistry (ISSAAD), and two years laterorganised a consensus conference on the subject of sedationand anaesthesia in dentistry. Israel’s dental schools, theMinistry of Health, anaesthesiologists, lawyers and dentistswere all included.The consensus conference resulted in guidelines for sedationand anaesthesia published by the Ministry of Health. Threeconsecutive updates (2002, 2003 and 2005) of the originalguidelines have been published by the Ministry.According to the guidelines:1. Dentists can practise inhalational sedation, enteral and

parenteral sedation, and a combination of the above.They can also treat patients under general anaesthesiaprovided that a specialist anaesthesiologist administersthe actual general anaesthesia.

2. The personnel required for inhalational sedation aredentist and assistant; for conscious sedation, dentist,assistant and a third person; and for deep sedation andGA, anaesthesiologist, dentist, assistant and a fourthperson.

3. Training in inhalational sedation is undergone bysenior-year undergraduate dental students. Training inconscious sedation (enteral and parenteral with orwithout nitrous oxide) and dentistry under generalanaesthesia is provided by dental specialty programmes(OMS, Dental Pediatrics, Oral Medicine, Periodontics).General practitioners can be qualified in these fieldsthrough continuing education courses.

The required facilities for inhalational sedation are nitrousoxide and oxygen gas delivery and evacuation systems. Forenteral and parenteral conscious sedation, monitors (BP,oximeter and capnograph) to ensure consciousness and toprevent the patient from sinking into unconsciousness, andan emergency kit (adrenalin, bronchial dilators, coronaryartery dilators, IV fluid kit, ambo and face masks and oxygenflow at 20 L/min for ½ h) are required.

2005 CONFERENCE


After a recent mortality resulting from enteral sedation in aprivate paediatric dental office, Israeli anaesthesiologistshave been criticising dental sedation.

Current sedation practicein PortugalJosé Mário Martins, Stomatologist and PhD student,University of Santiago de Compostela, Portugal

After a short update on demographic and geographic aspectsof Portugal, the author discussed the position of stomatologistsand dentists within the Portuguese oral health field, revealingthe differences at graduation and, later, during work.He went on to give a detailed overview of teaching, both atundergraduate and postgraduate level, concentrating onobjectives, scope and skills.The different sedation techniques used (mainly oral,intravenous, transmucosal and inhalational) were explained.The population normally receiving such treatments wasdiscussed, as well as aspects concerning limitations ontechniques for the administration of sedation. There was afocus on legal improvements aimed at reaching a moreefficient and safer practice.The author went on to present his view of the future, both inthe legal and teaching fields, concerning oral healthcare forspecial-needs patients.

Current sedation practicein the NetherlandsPeter C. Makkes DDS, PhDCentre for Special Dental Care, Amsterdam,The Netherlands

Dental care in the Netherlands has a limited tradition ofusing pharmacological supportive means to control anxietyand fear before and during dental treatment.

What sort of sedation is practised in your country?Oral sedation, nitrous oxide sedation and intravenous sedation.

Who provides sedation – dentists and/or doctors?Oral sedation and nitrous oxide sedation are provided bydentists. Intravenous sedation must be provided by ananaesthesiologist.

What are the limitations on providing sedation?There are no limitations for a dentist providing oral sedationor nitrous oxide sedation, or for an anaesthesiologistproviding intravenous sedation.

Are there any published guidelines or standards?There are published guidelines for oral sedation and nitrousoxide sedation. For intravenous sedation, guidelines areprovided in hospitals and centres for special dental care.

What teaching is carried out in sedation, and do undergraduatedental students gain experience in sedation?For oral sedation teaching provision is via sharing of personalexperience and expertise. For nitrous oxide sedation there isa six-day postgraduate course. Dental students get sometheory, and if they have the opportunity can be present whena patient is treated under sedation. There is no teaching inintravenous sedation for dentists or students.

Any recent developments?Developments in intravenous sedation have been in thedirection of more office-based facilities, with a tendencytowards single-drug intravenous anaesthesia.

Current sedation practicein GermanyMonika DaubländerUniversity Hospital, Mainz, Germany

Traditionally, dental treatment is performed under localanaesthesia alone in Germany. In the past, normally onlysurgical procedures were stated to require more than that foradequate pain management. Therefore, only maxillofacialand oral surgeons used sedation techniques. Nowadays,however, there is also growing interest among dentists ofother specialties (e. g. paediatric dentistry).Up to now there has been no teaching of sedationtechniques for undergraduate students at the 30 dentalschools in Germany. Most dentists are self-trained aftergraduation with about a third trained by specialists inGermany or in the US. Half of the dentists using sedationwork together with an anaesthetist in their office. Usually,oral sedation with benzodiazepines is used in both childrenand adults. Nitrous oxide only plays a minor role. The reasonfor this is the fear of side effects caused by prolongedexposure to the gas; this subject is raised by anaesthesiologists.In 2002 the German Society of Anaesthesiology publishedguidelines for sedation and analgesia for non-anaesthesiologists.These recommendations correspond very closely to theAmerican guidelines and include descriptions of aims andprerequisites for team, equipment and techniques. Althoughthey have been produced primarily for doctors, they are validfor dentists as well.Limitations on providing sedation in the dental office aregenerally due to the lack of training and the current law.

MENTORS FOR SEDATION


One of the barriers to the provision of conscious sedation

in practice is the difficulty in acquiringthe appropriate supervised clinicalexperience. The problem is that theStanding Dental Advisory Committeein its guidance indicates that suchexperience is required prior toindependent practice. Courses areeasily accessible. The SAAD coursehas never been more popular. Whathappens, though, when, fired withenthusiasm, the practitioner returns tohis or her practice? Unless it is a grouppractice that has a tradition ofproviding a sedation service, there is achance that the enthusiasm willevaporate unless the knowledge andskills attained are put into practice.

Diploma courses in sedation providethe opportunity to get experience, butthese are limited in numbers. A usefuloption is to develop a relationship witha ‘mentor’ who can guide the traineesedationist through the early stages ofgaining clinical experience.

Mentor listsBoth SAAD and the DSTG have listsof experienced sedationists who areprepared to act as mentors. Neitherorganisation takes any responsibility forthe training that occurs duringmentoring, but merely provides thecontact.

A mentor is defined as a ‘tutor’ or ‘wisecounsellor’. The word comes from theGreek tutor of Telemachus, the son ofOdysseus.

After introductionAfter making contact, how best toproceed? (Attendance at a sedationcourse is assumed.) The first step is toattend the mentor’s clinic to observe afew cases. Following this, the next stepwould be to book in some of thetrainee’s patients for sedation, either inthe trainee’s practice if properlyequipped, or in the mentor’s clinic ifnot. The mentor then should attend

the trainee’s clinic, both to advise onequipment and literature and tosupervise some sedations. It is usefulto involve both dental nurses in thetraining process.

The amount of experience requireddepends on the sedation techniquesthat the trainee wishes to learn.Competency in intravenous sedationis usually acquired after about 20mentored cases, while competency ininhalational sedation usually requiresabout 10 cases. It is important not toforget the assessment of sedationpatients, as this is a very importantpart of the sedation process. Althoughthe mentor is unlikely to be present atthe assessment appointments in thetrainee’s practice during assessmentsthe trainee could arrange for anypatients he or she is unsure of toattend when the mentor is present.There will also be the opportunity todiscuss the findings at the assessmentappointment prior to thecommencement of treatment.

MENTORS FOR SEDATIONDerek Debuse - Hon. Sec. SAAD

MENTORS FOR SEDATION


The completion of this amount ofsupervised clinical practice wouldallow the trainee’s dental nurse toacquire the level of experience thatwould equate to completing the logsheet sections of the portfolio for theCertificate in Dental SedationNursing awarded by the NationalExamining Board for Dental Nurses.

Once the trainee and mentor arehappy with the training, the first ‘soloflight’ can be booked. The ideal patientto start with is one who has been seenbefore, is ASA I, with good veins andwho responded well to sedation lasttime.

FeesPayment for the services of a mentor issomething that should be arrangedbeforehand and agreed. A fee shouldbe paid if the mentor takes time out ofhis or her practice to supervise. Thearrangements should be transparentand agreed by both parties. Thedefence organisations advise that ashort written agreement is prepared sothat there is no misunderstanding.

Medico-legalsituationOther medico-legal considerations arethat the patient should sign in theconsent form that they are aware thatthey are being treated by a dentistunder expert supervision.Responsibility for the sedation undertraining circumstances lies with thementor, while the treatment itself isthe responsibility of the operatingdentist. The practice owner takesultimate responsibility for thewellbeing of the patient.

IndependentpracticeIt is desirable that the mentor keeps incontact so that the trainee can ask foradvice if needed. The trainee willinevitably come across situations ofwhich he or she is unsure during theinitial steps as a trained sedationist.Extending the range of competency issomething that comes with experience.Having someone to discuss problems

with is a useful help. Better to askbefore rather than after a problem!

The list ofmentorsSAAD and DSTG welcome otherswho would like to join the list ofmentors. If having read this article youwould like to join the list pleasecomplete the enclosed applicationform or contact SAAD Hon. Secretary([email protected]). If having readthis article you would like to bementored please contact SAAD [email protected] and a list ofmentors will be sent.

FORUM


Welcome to the discussion forum. This forum isincluded to allow the readers of SAAD Digest to

ask questions or raise topics for debate. Questionssubmitted to the Editorial Board will be included alongwith an answer from a suitable “expert” suggested by theboard.

SAAD can take no responsibility for the accuracy of theanswers! We do hope that you will use this to ask thosequestions you always wanted to ask but were too afraid!All questions and answers will be published anony-mously!

HOW LONG AFTER SEDATIONCAN A PATIENT DRIVE?In fit, healthy people the elimination half-life of midazolamis 1.5 to 2.5 hours. This may be prolonged up to four timesin the over-60s. The elimination half-life of propofol is 30to 60 minutes; this is prolonged by a recirculation of thedrug for elimination from the poorly perfused areas of thebody, e.g. fat. Metabolism is mainly in the liver and themetabolites are pharmacologically inactive.

After five hours your patient may well still have a quarter ofthe dose of midazolam active in the body. Best advice wouldtherefore be that a patient should wait until the followingmorning before driving. Frequently patients are advised notto return to normal activity for 24 hours after sedation.Strictly following this recommendation would mean patientshaving to take part of the day following treatment off workand arrange supervision. This is both impractical and largelyunnecessary. As a result it is unlikely to be adhered to! Aswith all things patients do vary and some patients will notfeel recovered the following day. It is wise to tell patients thatthey should be fully recovered the following day, but if indoubt not to return to normal activity, but seek advice. Theproblem of prolonged recovery is more likely in older patients(over-60s) although there is a larger variation betweenchronological and biological age in many cases.

Propofol is cleared more quickly, but to keep things simpleand not confuse patients who may be sedated with differentagents at different times, the advice should be the same.

IS CONSCIOUS SEDATION SAFEFOR PATIENTS WITH ASTHMA?Patients with mild and well controlled asthma can safely besedated in practice, but, as with normal treatment, the stressof a dental appointment may be enough to trigger an attackand so you should be prepared. In addition, asthmaticshave a lowered respiratory reserve, so good oxygenationthroughout the procedure is essential.

Make sure your patient has their normal medication on theday of treatment and that you have appropriate emergencydrugs available. It is worth ensuring that the patient bringshis or her own medication and that it is available in thesurgery. Either inhalational sedation or intravenous sedationis appropriate. Nitrous oxide is not an irritant to the airwayand therefore does not induce asthma attacks, and as thosebeing given inhalational sedation are receiving more oxygenthan when breathing normal air, this has obviousadvantages. The benzodiazepines do not cause histaminerelease and so are safe to use in this group.

The reduction of stress in this group of patients means thatby sensibly using sedation techniques we can reduce theincidence of medical incidents in the practice of dentistry.

DOES CONSCIOUS SEDATION HELPWITH PATIENTS WHO GAG WHENCONVENTIONAL TREATMENT IS PROVIDED?The first-choice technique in these patients is inhalationalsedation with nitrous oxide and oxygen. This technique hasbeen shown to be useful in a large number of patients. If itis unsuccessful, then, since intravenous benzodiazepinesinhibit the pharyngeal gag reflex, intravenous sedation canbe used.

There is no guaranteed solution to this problem and inmany ways this group presents one of the biggestchallenges to the sedationist!

WHAT ANALGESIC DO YOU RECOMMENDFOR USE DURING AND POST-SEDATION?Analgesia during the treatment is usually provided by theadministration of local anaesthetic solutions. This will alsoprovide analgesia for the immediate postoperative period. Ifpostoperative analgesia is required, then non steroidal antiinflammatory drugs are the agents of choice. There isevidence in the literature that these are the mostappropriate agents.

DISCUSSIONFORUM

DSTG REPORT


Carole Boyle, Chairman of DSTG, opened the Annual Symposium, the theme of which was ‘guidelines’ and

the processes undertaken to ensure their development intoscientifically robust documents. She also thanked RAMedical Services and Blackwell Anaesthetic Supplies fortheir generous sponsorship of the Symposium.

Carole detailed the various tasks delegates were toundertake during the day, i.e. to review and providefeedback on draft versions of Conscious Sedation inDentistry, developed by the National Dental AdvisoryCommittee for Clinical Effectiveness (NDAC) of Scotland,the DSTG document Training in Conscious Sedation forDentistry (2005), and also the substantive documentConscious Sedation in the Provision of Dental Care (2003),produced by the Standing Dental Advisory Committee(SDAC) of the Department of Health.

It was fitting that the meeting was held north of the borderas Archie Cochrane, a visionary Scottish physician, was thecatalyst for the establishment of the CochraneCollaboration – a network that focuses on systematic up-to-date reviews of randomised controlled healthcare trials.

The first session, chaired by Jan Clarkson, Director ofNDAC, explored the evidence used to formulate paediatricsedation guidelines and the ‘validating process’.

Dr Paul Ashley, Programme Director at the Unit ofPaediatric Dentistry, The Eastman Dental Institute, gavethe first of two papers, ‘The Cochrane Review onPaediatric Sedation’.

The background to this Review was based on the premise,well appreciated and understood by dental surgeons, thatanxiety about dental treatment may be a barrier to itsuptake in children. Dr Ashley stated that conscioussedation may be used to relieve anxiety and managebehaviour, but that it is difficult to ascertain from published

research which agents, dosages and techniques areeffective.

The objectives of the Review were to evaluate the efficacyof various conscious sedation techniques and establishdosages for behaviour management in paediatric dentistry.

A computerised search of studies was undertaken, but of atotal of 141 potential studies only 61 were entered into theReview; many studies were excluded because of poorrandomisation. The selection criteria were those randomisedcontrolled trials (RCTs) that compared two or more drugs,techniques or placebo in children under the age of 16 years.

Interestingly, 50 per cent of the studies were from theUnited States of America, whose dentistry traditionallytakes a different approach from the European way ofundertaking paediatric sedation. For example, papooseboards were used in 46 per cent of the studies and nitrousoxide or oxygen administered as a supplementary agent in34 per cent. The characteristics of the subjects were a youngage (in 44 per cent of the studies the age was 6 years orless, with a mean of 4.6 years), and 84 per cent of childrenwere deemed to be ‘anxious at a baseline measurement’.The total number of children in the Review was 3,246.

Paul explained that while specialist advice was sought tocategorise interventions it was difficult to isolate groups ofstudies that were sufficiently similar in design to allow sensiblecomparison. Where groups could be isolated the differingoutcome measures used made meta-analysis impossible.The overall quality of the studies was disappointing.

Two underlying outcomes of the Review were, firstly, that itwas not possible to reach any definitive conclusion for themost effective drug or method of sedation to use in anxiouschildren and, secondly, that it would be a good idea todevelop international guidelines to ensure enhancedcomparability of studies.

DENTAL SEDATION TEACHERS GROUPANNUAL SYMPOSIUMROYAL COLLEGE OF SURGEONS, GLASGOW, 26 APRIL 2005

DSTG REPORT


As Cochrane Reviews have high standards it is essentialthat better research in paediatric sedation be undertaken.

Douglas Stirling, Senior Researcher, NDAC, presented thesecond paper. The NDAC covers all sections of the dentalprofession in Scotland and reports to their Chief DentalOfficer. The function of this committee is to provide user-friendly, evidence-based clinical guidelines in seven priorityareas in dentistry, with one of these being conscious sedation.

For each of these seven areas, a Chairperson leads aDevelopmental Group comprising , usually, eightrepresentatives drawn from the General Dental Service,Professionals Complementary to Dentistry and an academicspecialist. Guidance Support Teams and an overarchingSteering Group exist to facilitate and strengthen this process.

It was pointed out that dentistry has to compete with otherorganisations for guidelines development, for example,SIGN and NICE, and that up-to-date guidelines wereneeded in an era of evolving legislation.

The five steps of the development process were stated as:1. Remit and scope2. Retrieval and appraisal3. Draft document production and consultation process4. Review and revision5. Publication

The definition of the term ‘clinical guidelines’ is stated inthe draft document, and Douglas described AGREE(Appraisal of Guidelines Research and Evaluation), whichis an international standard that assesses the quality of themethodology in guidelines development. There are six areasthat are used in this evaluation process:

1. Scope and purpose2. Stakeholder involvement3. Rigour of development4. Clarity and presentation5. Applicability6. Editorial independence

By consideration of these areas, the ensuing guidelinesrecommendations should be both internally and externallyvalid and feasible for practice.

Douglas then considered aspects of four current conscioussedation guidelines.

At the conclusion of these very comprehensive and detailedpresentations, Paul, Douglas and Jan fielded severalquestions from delegates that related to the implications of

the young age of the subjects in the Cochrane Review andhow the seven priority areas were selected by the NDAC.

Jeremy Bragg, Chairman of the NDAC, chaired the secondsession which was entitled ‘The NDAC and SDACSedation Guidelines: A Debate’. The objectives for thissession were explained by Nigel Robb, Senior Lecturer inSedation in Relation to Dentistry, University of GlasgowDental Hospital and School, NDAC Steering Group andDavid Craig, Head of Department/Associate Specialist inSedation, GKT Dental Institute, London. Delegates wereto consider and make recommendations to improve thedraft versions of the NDAC and DSTG sedationdocuments and also to the published SDAC sedationdocument.

Page three of the draft NDAC paper was headed ‘KeyRecommendations - to be confirmed after consultation’,thus permitting DSTG members the opportunity toinfluence the end product.

Nigel and David suggested an array of areas to consider forrevision and/or extension. This certainly was not a passiveday! Delegates were allocated to one of four working groupsand dispersed to various meeting rooms.

The salient feedback points from this consultation processcan be summarised as follows:

1. Improved accessLargely dependent on Primary Care Trusts (PCTs),who must commission sedation services in the primarycare setting.Strategic Health Authorities should ensure that sedationis on PCTs’ agendas.

2. Specialist centresThere was strong support for their establishment,subject to well-defined regulation.Some concerns were raised that, as dental sedation is arelatively low-risk clinical activity, there was a dangerthat over-regulation might inhibit dentists in theprimary care setting from undertaking this valuableservice.

3. TrainingEssential for undergraduates to be trained in basicdental sedation skills.Need for outreach training centres in order to improveopportunities for ‘hands-on’ experience.Important to develop dentists with a special interest inconscious sedation.

DSTG REPORT


4. Research and developmentDentists operating in the primary care setting andacademic staff to be linked to develop large trials withthe focus on ‘the big questions’.

5. Audit and clinical governanceDeemed imperative to ensure high quality standards.Networks should be established to promote this and todisseminate results of sedation-related significant eventincident analysis.All dental sedationists should keep a CPD logbook.A ‘dental team leader’ should oversee sedation in dentalpractice, with the General Medical Council responsibleas the monitoring agency for medical practitionersinvolved in dental sedation.

6. NDAC sedation documentDelegates were impressed by the document, particularlythe inclusion of grades of recommendation, i.e.Mandatory, Recommended and Acceptable practice andNot Recommended, and also the level of evidence usedto support statements.The section on oral sedation stating that dentists shouldpossess skills in other titratable sedation techniques andbe skilled in cannulation was well received.

7. CriticismsSpecial-care dentistry did not receive an extensivemention.Need for a definition of ‘fully trained’.It was suggested that one set of guidelines would sufficefor the UK – a brave statement from this English groupleader in the heart of Scotland!

The morning session was then adjourned for the AnnualGeneral Meeting to be held.

Carole presented the minutes of the 2004 AGM that wereapproved. She then reflected on the progress the Grouphad made during the ten years since its establishment. ACouncil meeting held the previous day had debatedsedation teaching at dental schools; while there wereinevitable challenges, dental students were now graduatingwith ‘hands-on’ experience – overall it felt positive.Thanks were given to Chris Wright in his role as webmasterand to SAAD and ADA for their general support.It was not necessary to hold elections for officers this yearbut many posts would be subject to the electoral process intwelve months’ time.

The Honorary Secretary, Paul Coulthard, explained that hehad written to the chairman of the Specialist Advisory

Committee to request that sedation be an integral part ofspecialist training. Paul was also in the process of updatingthe DSTG list of mentors.

Shelagh Thompson, Honorary Treasurer, presented thestatement of accounts for the year ending 31 March 2005;these were approved. Membership stood at 356; 42members had been recruited at the Liverpool Symposium.This would be Shelagh’s final year in the post.

Next year’s Symposium would be held in London.

There was time during the lunch break to visit the tradestands and meet representatives of companies dealing insedation-related equipment and materials.

The first session of the afternoon, chaired by Meg Skelly,was devoted to sedation teaching practice. Again, delegatesmet in their working groups to deliberate on the DSTG’sdraft document, Training in Conscious Sedation for Dentistry(2005), prior to giving feedback.

The DSTG had now fulfilled one of the essential steps ofguidelines development that had been described earlier inthe meeting by Douglas Stirling, i.e. the consultationprocess.

Several short free papers were then presented before Caroleclosed what had been a highly successful Symposium.

Report by Stephen Jones - Hon. Treasurer of SAAD.First published in the DSTG Newsletter and reproducedby kind permission of the author.

JOURNAL SCAN


SAAD DIGESTJOURNAL SCANMAY 2006Avril Macpherson

Abstracts are presented as originally publishedor with only minor modifications.

SEDATION OF ANXIOUS CHILDRENUNDERGOING DENTAL TREATMENT

Matharu, L. M., Ashley, P. F. Sedation of anxiouschildren undergoing dental treatment. CochraneDatabase of Systematic Reviews. 1, 2006.

OBJECTIVES:To evaluate the relative efficacy of the variousconscious sedation techniques and dosages forbehaviour management in paediatric dentistry.

SEARCH STRATEGY:Computerised: MEDLINE, PubMed, EMBASE,Cochrane Central Register of Controlled Trials,Dissertation Abstracts, SIGLE, the World WideWeb (Google) and the Community of ScienceDatabase were searched for relevant trials andreferences up to December 2004. Reference listsfrom relevant articles were scanned and the authorscontacted to identify trials and obtain additionalinformation. There were no language restrictions.Trials pre-1966 were not searched.

SELECTION CRITERIA:Studies were selected if they met the followingcriteria: randomised controlled trials of conscioussedation in anxious children up to 16 years of age,undertaken by the dentist or one of the dentalteam, comparing two or more drugs/techniques/placebo.

DATA COLLECTION AND ANALYSIS:Data regarding methods, participants, interventionsand outcome measures and results wereindependently extracted, in duplicate, by twoauthors. Authors of trials were contacted for detailsof randomisation and withdrawals and a qualityassessment was carried out, not using any formalscoring system. The Cochrane Oral Health Groupstatistical guidelines were followed.

MAIN RESULTS:61 studies were included with 3,246 subjects intotal. Overall quality of studies was found to bedisappointing, with poor reporting often the mainproblem. Data reported could not easily be

JOURNAL SCAN


aggregated into groups to facilitate description ofresults. Meta-analysis of the available data was alsonot possible for the same reason. The variety ofdiffering drug regimes compared made it difficultto isolate groups of studies that were sufficientlysimilar in design to allow sensible comparison.Where groups of studies could be isolated, thediffering outcome measures made their meta-analysis impossible.

CONCLUSIONS:Review authors were not able to reach any definitiveconclusion on which was the most effective drug ormethod of sedation used for anxious children. A listof proposed areas of study was described. Theauthors suggested that an international consensusshould be reached on trial design for studiesassessing sedation, to include such issues asblinding, sampling, trial design (crossover vs.parallel design), baseline and outcome variables andthe definition of sedation used.

EFFECT-SITE TARGETEDPATIENT-CONTROLLED SEDATIONWITH PROPOFOL:COMPARISON WITH ANAESTHETISTADMINISTRATION FORCOLONOSCOPY

Stonell, C. A., Leslie, K., Absalom, A. R. Effect-site targeted patient-controlled sedation withpropofol: comparison with anaesthetistadministration for colonoscopy. Anaesthesia. 2006;61(3): 240–7.

OBJECTIVE:Patient-controlled sedation (PCS) allows patientsto match their sedation requirements to perceived

discomfort. The significant delay in onset ofsedation may be overcome with effect-site steeredtarget-controlled infusion, but previously only trialsin volunteers have been carried out.

DESIGN:We therefore conducted a randomised, double-blind controlled trial comparing effect-site propofolPCS with anaesthetist-administered propofolsedation in 40 patients presenting for colonoscopy.The initial effect-site target in the PCS group was0.8 µg/ml-1, increment was 0.1 µg/ml-1 and lockoutwas three minutes.

RESULTS:Patient and endoscopist satisfaction and operatingconditions were similar between the two groups.PCS patients were sedated more slowly (13[7.1] vs.3[1.1] minutes; p< or = 0.0001) and less deeply(minimum BIS value: 71[16] vs. 58[15]; p = 0.13)than anaesthetist-administered propofol sedationpatients. More of the later patients werehypotensive, but all patients had a similarrecollection of events during the procedure and asimilar quality of recovery.

EMERGENCY DENTAL CLINICPATIENTS IN SOUTH DEVON,THEIR ANXIETY LEVELS, EXPRESSEDDEMAND FOR TREATMENT UNDERSEDATION AND SUITABILITY FORMANAGEMENT UNDER SEDATION.

Baker, R. A., Farrer, S., Perkins, V. J., Sanders, H.Emergency dental clinic patients in South Devon,their anxiety levels, expressed demand for treatmentunder sedation and suitability for management undersedation. Primary Dental Care. 2006; 13(1): 11–8.

JOURNAL SCAN


OBJECTIVE:To assess the anxiety levels of patients attendingtwo salaried dental service emergency clinics, theirexpressed demand for treatment under sedation,and their medical suitability for dental sedation.

DESIGN:A questionnaire survey, incorporating the ModifiedDental Anxiety Scale (MDAS) and assessment ofAmerican Society of Anesthesiologists (ASA)physical status classification, of all adult patientsattending two emergency dental clinics in Torbayand Newton Abbot.

RESULTS:513 patients returned questionnaires. Only 5declined to take part in the study. The meanMDAS score for patients attending the twoemergency dental clinics was 14.09 (SD 6.04), and41.9% of the patients were classified as dentallyanxious (MDAS > 15). A preference for treatmentunder sedation was expressed by 56.3% of allpatients, of whom 50.5% were classed as ASA 1(without health problems) and would have beensuitable for sedation in primary dental care.

CONCLUSIONS:The reported dental anxiety levels of patientsattending the two emergency dental clinics werefound to be much higher than those found byprevious studies in general dental practice and atdental school emergency clinics. There was a highexpressed demand for treatment under sedation.Further studies are needed to assess the level ofdental anxiety seen at other dental emergencyclinics, and a health needs assessment would berequired in order to determine need as opposed toexpressed demand.

THE EFFICACY OF ROPIVACAINE ASA DENTAL LOCAL ANAESTHETIC

Axelsson, S., Isacsson, G. The efficacy ofropivacaine as a dental local anaesthetic. SwedishDental Journal. 2004; 28(2): 85–91.

OBJECTIVE:To investigate the efficacy of ropivacaine indentistry.

DESIGN:This open-labelled, parallel-group study included41 subjects randomised to 1 ml or 2 ml ropivacaine7.5 mg/ml and to maxillary infiltration or nerveblock of the inferior alveolar nerve. Pinprick pain,electrical pulp testing and numbness were used asefficacy measures. Following onset, the duration wasmeasured until baseline status was re-established orafter a maximum of six hours.

RESULTS:A high frequency of anaesthesia was obtained. Thepulpal anaesthesia mean onset times were 2.1 and1.6 minutes after end of infiltration and 2.9 and4.5 minutes following end of nerve block injectionfor the 1 ml and 2 ml ropivacaine respectively.Pulpal anaesthesia mean duration was 0.4 and 1.3hours after infiltration and 3.7 and 4.3 hours fornerve block, respectively. The mean lip numbnessduration ranged from 3.7 to 5.1 hours for theupper lip and from 7.5 to 8.4 for the lower lip.

CONCLUSION:1 ml and 2 ml ropivacaine 7.5 mg/ml provided ahigh frequency of anaesthesia with short onset timeand long duration following nerve block.Ropivacaine may be suitable for time-consumingoral procedures and/or when post-operativeanalgesia is desirable.

PRODUCT NEWS


ORAQIX ANAESTHETIC GEL

Figure 1. Oraqix packaging

Figure 2. CartridgeThe air bubble is intentionally larger. Whenliquid the bubble will move as the cartridgeis tilted.

Figure 4, 5. Application

Figure 3.Unassembled Dispenser

Oraqix is a non-injectable dentalanaesthetic indicated in adults for

localised anaesthesia in periodontalpockets for diagnostic and treatmentprocedures such as probing, scaling androot planing.

WHAT DOES IT CONTAIN?Oraqix contains 2.5% lidocaine and 2.5%prilocaine (25mg/ml of each), and is thusa 5% solution of local anaesthetic agents,which are contained in a gel that sets atbody temperature. It thus has the sameactive ingredients as EMLA, the topicalskin anaesthetic used prior to intravenouscannulation. The difference is thatEMLA becomes more liquid at highertemperatures and Oraqix sets!

PRESENTATIONOraqix is provided in glass cartridgessupplied in a box of 20. Each cartridge issupplied with a blunt applicator, whichwill prevent the gel from being injected. Aspecial dispenser is available, which doesnot look like a syringe. This is beneficialwhen managing anxious or needle-phobic patients! (Figures 1, 2 and 3)

CLINICAL USAGE ANDACTIONOraqix is introduced into the periodontalpocket/gingival crevice of the tooth orteeth to be treated. When introduced, itneeds to be cool enough to be liquid.Once in the periodontal pocket, it warmsand sets. Thus, it stays where it is put.(Figures 4 and 5)

Onset of anaesthesia is within 30 secondsof application and the duration of action isapproximately 20 minutes. If necessary,Oraqix can be reapplied, provided thatthe maximum dose is not exceeded.

Oraqix provides soft tissue anaesthesia,not pulpal anaesthesia.

DOSAGEThe maximum dose per session is 5cartridges or 8.5g of Oraqix. If used incombination with other topical orinjectable local anaesthetics, themaximum dose must be reduced. If 50%of the maximum dose of an injectablelocal anaesthetic is used, only 50% of themaximum dose of Oraqix can be used.

PATIENT PERCEPTIONEarly reports suggest that Oraqix ispopular with patients. This is becausethere is no need for an injection, and thereis a lack of post-operative soft tissuenumbness (provided that the patientdoes not lick the site of application).

Oraqix provides effective soft-tissueanaesthesia for scaling and root planing,and in comparative studies, althoughsometimes superior anaesthesia isobtained with injectable localanaesthetics, 70% of patients preferredOraqix for treatment.

DENTAL TEAM PERSPECTIVEDentists and PCDs who have usedOraqix like the product, and it is gainingwider acceptance in dental practice.

CAN IT BE USED FOR OTHERTHINGS?Although only licensed for periodontalprocedures in adults, dentists may chooseto use it for other gingival manipulationssuch as retraction cord placement, matrixband placement or prior to the use of arubber dam clamp.

CONCLUSIONThis agent has the potential to makenon-surgical periodontal treatment moreacceptable for patients.

For further information contact yourDentsply representative.


Members Non- Postagemembers

Intravenous SedationPresedation instructions (per 200)

£17.50 £22.50 £7.80*

Dental Treatmentfor Anxious Patients £17.50 £22.50 £7.80*Information brochure (per 200)

Medical History Forms(per 200)

£15.00 £20.00 £5.15*

Sedation Record Forms(per 200)

£15.00 £20.00 £5.15*

Standards in Conscious50p 50p –Sedation for Dentistry

Conscious Sedation:A Referral Guide for Dentists.

50p 50p –

*If four or more items are ordered together, the postage and packing will be £15.60

Order forms are available from• www.saaduk.org • SAAD Supplies• [email protected] 21 Portland Place• 020 7631 8893 LONDON W1B 1PY

For further information please refer to www.saaduk.org or contact Fiona Wraith [email protected] or 01302 846149

SAAD Supplies


SAADSubscriptions

Subscription fees for 2006 fell due in January 2006.

If you are unsure if you have paid your subscription feesplease contact [email protected] or 020 7631 8893.

The subscription fees remain:

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Overseas members subscription fee £28 per annum

There are three payment methods now available:

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020 7631 8893 or www.saaduk.org for a form)

SAAD Membership Subscriptions21, Portland Place

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Annual Conference and AGM

‘Pain andAnxiety Control in

Medicine and Dentistry’

Saturday 23 September 2006

Royal Society of Medicine1 Wimpole Street, London

Enquiries:SAAD, 21 Portland Place, London W1B 1PY

020 7631 8893 | [email protected] | www.saaduk.org

GUIDELINES FOR AUTHORS


The SAAD Digest accepts manuscripts either by email or mail.

MANUSCRIPTS should be word-processed in Microsoft Wordformat and double-spaced with a margin of at least 4 cm on theleft-hand side. The pages should be numbered consecutively withnumbers centred at the bottom of each page. The first page ofthe manuscript should give only the title of the article, and theauthor’s/authors’ name(s), qualifications and address(es).

SUBMISSION: in the case of paper submission, authors shouldsend two copies of their paper to: Fiona Wraith, ExecutiveSecretary, SAAD, 21 Portland Place, London, W1B 1PY. Acopy of the paper on disc should also be submitted.

Authors are also encouraged to submit their manuscripts viaemail to [email protected].

In both cases the submission should be accompanied by acovering letter signed by all of the authors.

PEER REVIEW is by at least two referees and the Chairman ofthe Editorial Board. Statistical advice may be sought if feltappropriate.

LENGTH OF CONTRIBUTIONS: ideally, contributions shouldbe no more than 3,000 words, including tables and figures. Tablesand figures will count as 100 words. Case reports may besubmitted, but should be no more than 750 words in length.

Titles must be descriptive of the contents of the article, but yetconcise. Papers should be introduced with a short abstract.

ABSTRACTS should be able to stand alone. The abstract shouldnot contain references or abbreviations, and should be no longerthan 200 words.

DATA AND TABLES may be submitted in Microsoft Excelformat or embedded in the text of the Word document. Figuresor images should be submitted as external files in TIFF, JPEG orEPS format. The SAAD Digest is published in colour and colourillustrations are preferred.

ILLUSTRATIONS: If a person is recognisable from a photograph,written consent must be obtained prior to publication, and a copysent to [email protected]. The submission of electronicimages on disc or by email is preferred. If submitting hard copy,please do not submit the original until the manuscript has beenaccepted for publication. Once the manuscript has beenaccepted, the submission of photographs or slides for professionalscanning is required.

Units used in the manuscript must conform to the SystèmeInternational d’Unités (SI).

REFERENCES must be in the Vancouver style. They should benumbered in the order in which they appear in the text. Thenumbers should be inserted in superscript each time the author iscited (‘Jones2 reported . . .’ or ‘Smith et al3 found . . .’ or ‘Otherreports5 have . . .’). A full list of references must be provided at

the end of each manuscript. The reference list should give thenames and initials of all the authors unless there are more thansix, in which case only the first three should be given in full,followed by et al. The authors are followed by the title of thearticle; the journal title abbreviated as per Index Medicus andIndex to Dental Literature; year of publication; volume number;and first and last page numbers in full. Titles of books should befollowed by the place of publication; publisher; and year.

Examples of reference style:

Reference to an article1. Chadwick B L, White D A, Morris A J, Evans D, Pitts,

N B. Non-carious tooth conditions in children in the UK,2003. Br Dent J 2006; 200(7):379–384

Reference to a book3. Craig D C, Skelly A M. Practical Conscious Sedation.

pp1-10. London: Quintessence; 2004.

Reference to a book chapter6. Robb N D. Conscious sedation in dentistry. In Heasman

PA (ed) Master Dentistry Vol. 2: Restorative Dentistry,Paediatric Dentistry and Orthodontics. pp 149–168.Edinburgh: Churchill Livingstone, 2003.

Reference to a report9. GDC. Reaccreditation and recertification for the dental

profession. London: GDC; 1997.

RESPONSIBILITY OF THE AUTHOR/PRINCIPAL AUTHOR:the author is responsible for the accuracy of the reference list forthe article. It is a condition of the acceptance of manuscripts thatthey are solely the work of the author(s) listed on the first pageof the manuscript and have neither been previously published norare under consideration for publication in any other journal.

ETHICS: articles reporting clinical research should include astatement indicating that Ethical Committee approval has beengranted.

ACKNOWLEDGEMENTS should be included in one paragraphbetween the text and the references. Permission and approval ofthe wording must be obtained from those who are listed. In thecase of research supported by industry, this must beacknowledged in the covering letter or email on submission ofthe manuscript.

COPYRIGHT: it is assumed that the author(s) assign(s) copyrightof the article to the Society for the Advancement of Anaesthesiain Dentistry upon acceptance. Single copies for personal studymay be made free of charge. Multiple copies will requirepermission from the Society for the Advancement ofAnaesthesia in Dentistry prior to production.

The Editorial Board reserve the right to edit the manuscripts forclarity and to conform to acceptable style and the space availablefor publication. Proofs will be supplied for correction ofmisprints – material changes can only be made in exceptionalcircumstances.

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The Drummond-JacksonEssay Prize

A PRIZE OF £1000FOR DENTAL AND MEDICAL

UNDERGRADUATES AND GRADUATES You are invited to express your views on any subject related toCONSCIOUS SEDATION, ANALGESIA, ANXIETY CONTROL

OR GENERAL ANAESTHESIA FOR DENTISTRY• The essay should be in ENGLISH on A4 paper, double spaced, and formatted

on disc as a Microsoft word document and not to exceed 5,000 words• The paper should be an original publication and SAAD reserve the right

to publish until the winner has been decided• The winner may be invited to present the paper at an appropriate SAAD

scientific meeting• Entries must be received by 31st October 2006• The decision of the panel of assessors appointed by SAAD will be final• Entries, accompanied by name & address, should be sent to :-

SAAD Drummond-Jackson Prize 21 Portland PlaceLONDON W1B 1PY

www.saaduk.org

www.kenes.com.esta

Society for the Advancement of Anaesthesia in Dentistry

DIARY SCAN COMPILED BY CHRISTOPHER MERCER


2006 DATE ORGANISATION THEME/TITLE VENUE CONTACT

JUNE

3–6 Euroanaesthesia 2006 IFEMA Centre, Madrid www.euroanesthesia.org

21–23 AAGBI GAT Annual Scientific Newcastle upon Tyne, www.aagbi.org/gat_asm.htmlMeeting Civic Centre

23–24 Association of Summer Meeting Dundee [email protected] Anaesthetists

JULY

1–2 SAAD National Course in London [email protected] Sedationfor Dentistry

AUGUST

SEPTEMBER

6–9 ESRA XXV Annual ESRA Congress Monaco www.optionsglobal.com

19–22 AAGBI Annual Congress 2006 Aberdeen [email protected]

23 SAAD Pain and Anxiety Control London www.saaduk.orgin Medicine and Dentistry [email protected]

020 7631 8893

OCTOBER

4–7 IFDAS 11th International Pacifico Centre, www.ifdas2006.comDental Congress on Yokohama City, JapanModern Pain Control

NOVEMBER

4–5 SAAD National Course in London [email protected] Sedationfor Dentistry

23–24 UK Society Annual Scientific Meeting Chepstow www.sivauk.orgfor IntravenousAnaesthesia

DECEMBER

2007

DECEMBER

13–14 UK Society Annual Scientific Meeting Queens‘ College, www.Cambridge2007.orgfor Intravenous CambridgeAnaesthesia

SAAD DIGEST

JOURNAL OF THESOCIETY FOR THE ADVANCEMENTOF ANAESTHESIA IN DENTISTRY

VOLUME 22 | MAY 2006

2005 ConferenceOutcomes of PatientsReferred tothe Sedation Suite

Mentors for Sedation

Documents

OF ANAESTHESIA IN DENTISTRY SOCIETY FOR THE ADVANCEMENT ...s540821202.websitehome.co.uk/Wordpress2/wp-content/uploads/20… · treatment under local anaesthesia’ using conscious